Connected Health Initiative Outlines Federal Policy Recommendations

ACT | The App Association's Connected Health Initiative (CHI) recently submitted a letter to the White House outlining a number of recommendations for telehealth and connected health technologies.

The letter follows a recent telehealth briefing held by CHI, and is in response to a White House official's request for recommendations that support telehealth adoption, but do not require congressional action or new regulation. In the letter, the group argues that the government can stimulate the sector through several policy levers.

The group would like to see the Centers for Medicare and Medicaid Services (CMS) create new CPT codes and adopt unbundled CPT codes that value the use of remote monitoring as well as waive telehealth restrictions for shared savings programs and alternative payment models (APMs) and accountable care organizations (ACOs) election to ensure there are no limits on the use of store-and-forward technologies. The organization also recommends that CMS offer waivers and incentive payments more broadly to Medicare providers to optimize multiple provider types and support virtual Diabetes Self-Management Training (DSMT) and include CDC-recognized virtual diabetes prevention program providers in the Medicare Diabetes Prevention Program (MDPP).

In the context of Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) implementation, CHI recommends that CMS use an outcome-based approach to support the inclusion of telehealth and remote monitoring within the Quality Payment Program and support CMS’ adoption of the Connected Health Initiative’s MIPS improvement activity, which supports doctor’s review of patient generated health data. The group also is recommending that CMS allow Medicare Part C Advantage health plans to use telehealth and RM services as a basic benefit of service.

The organization also has recommendations for the Drug Enforcement Administration (DEA). It is recommending that the DEA reduce its regulations to foster innovation and competition in the electronic prescribing of controlled substances (EPCS), particularly as the opioid epidemic continues to grow. “These regulations currently prevent innovators, and particularly small business innovators, from participating in the EPCS market,” the organization wrote.

The organization recommends removing certain requirements that would help to make electronic prescribing of controlled substances software more efficient and affordable for clinicians.

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Current events and issues, such as the opioid epidemic, are increasing the need to provide telehealth services

Stakeholders’ recognition of telehealth benefits has continually increased, as doors are now opening for various subsets of medicine, including tele-mental health, according to new research from law firm Epstein Becker Green (EBG).

The 2018 Tele-mental Health Laws survey provides an update to state telehealth laws, regulations, and policies for mental and behavioral health practitioners and stakeholders across all 50 states and the District of Columbia. The survey’s researchers said that in the last few years, “the public’s and the healthcare industry’s recognition of the benefits of telehealth has continually increased. While the shortage of behavioral health providers has long been acknowledged, the use of telehealth technologies, including practice management systems and online patient portals, to provide greater access to behavioral health professionals has increasingly gained traction and continues to gain validation as an alternative model of care delivery.”

What’s more, EBG also found that current events and issues, such as the opioid epidemic, have put more pressure than ever before on federal and state legislators to pass laws that promote access to, and provide guidance for, providers seeking to utilize telehealth services.

The survey revealed various reasons for the increase of access to tele-mental health services, and telehealth services overall, including:

Bipartisan support: The Bipartisan Budget Act of 2018 signed into law in February expanded Medicare coverage for certain telehealth services to beneficiaries who are being treated by practitioners participating in accountable care organizations (ACOs).

Greater advocacy from Medicare & Medicaid: In June 2018, the Centers for Medicare & Medicaid Services (CMS) publicly encouraged states to utilize telemedicine and telepsychiatry to facilitate coordinated care for Medicaid recipients. As of August 2018, 49 states and the District of Columbia provide reimbursement for live video telehealth services through Medicaid fee-for-service programs.Massachusetts is the only state not yet participating.

The opioid epidemic: Several states, including Indiana, Michigan, and Missouri, have introduced and/or passed legislation that expands remote prescribing of controlled substances for treatment of substance use disorders (SUDs). In October 2018, President Trump signed into law H.R. 6, the Substance Use-Disorder Prevention that Promotes Opioid Recovery and Treatment (“SUPPORT”) for Patients and Communities Act.

This year’s survey also looked at positive trends in telehealth adoption and usage models, including: school sites and pediatric care; the Department of Veterans Affairs’ expanded telehealth programs (since its rollout, the VA’s telehealth program has onboarded approximately 20,000 new patients and hosts more than 6,000 virtual visits each week); and the promotion of care models for growing aging-in-place populations.

Despite the continued telehealth momentum, several barriers and policy variances do remain, the researchers stated. Some of these include: limited federal guidance on coverage and reimbursement and the lack of meaningful coverage by third-party payors, the report said. To this end, A recent MedPAC survey noted that coverage of telehealth services continues to vary widely across commercial health plans, with most covering only one or two types of telehealth-based services.

“While telehealth parity laws are currently in effect in 39 states and the District of Columbia and are intended to ensure the same coverage of (and in some cases, reimbursement for) telehealth services, there is more work ahead to achieve comprehensive coverage and access. States must continue to enact new parity laws or expand existing ones,” the researchers stated.

Healthcare organizations report high satisfaction with their telehealth virtual care platforms (VCPs), however there are significant differences in how broad the various platforms are and in the quality of the vendors’ service. What’s more, integration with electronic health record (EHR) systems is a key challenge facing every telehealth vendor, according to a KLAS report.

In its report, “Telehealth Virtual Care Platforms 2019: Which Telehealth Vendors Have the Scalability Customers Need?,” KLAS evaluates some of the top telehealth companies including American Well, MDLive and Epic, and analyzes what capabilities will set vendors apart as more healthcare organizations adopt virtual health technology solutions.

Most virtual care platform vendors receive positive performance ratings, but the depth and breadth of their capabilities vary, and this can impact scalability for organizations looking to grow, according to KLAS. No two vendors are alike in their capabilities, offering different combinations of functionality and experience.

Of the companies KLAS evaluated, the most common type of visit varied—most of American Well’s visits were on-demand urgent care, while the majority of Epic’s visits were associated with virtual clinic visits.

A key factor of scalability is the ability to support multiple visit types, KLAS researchers note. While multiple vendors offer support for all three visit types (on-demand or urgent care, virtual clinic visits and telespecialty consultations) no single vendor has a large proportion of customers using all three (only 12 respondents across all vendors said they were doing so).

American Well, a market share and mindshare leader, and MDLIVE, two of the vendors used most frequently for multiple visit types, receive generally positive—but lower than average—performance scores. Vendors more specialized in specific visit types or component layers (e.g., Vidyo and Zipnosis) have high scores but narrower expectations from customers.

No one vendor meets all needs equally well, but several are reaching for “all-purpose” status with internal development and/or recent acquisitions (American Well acquired Avizia; InTouch acquired TruClinic), according to the report.

KLAS’ analysis also uncovered a general trend of poor integration. In most cases, the addition of a virtual care platform also means the introduction of a second EHR into the clinician workflow.

“Although integration between EMRs is generally understood to be important for care quality, patient safety, efficiency, and productivity, few interviewed VCP customers have full bidirectional transfer in place. Most say that they are too early in their virtual care programs to pursue integration or that it simply costs too much,” KLAS researchers wrote.

Only American Well, Epic, and MDLIVE have more than half of interviewed customers currently on an integrated path, KLAS found. Epic has placed virtual care capabilities directly into their top-rated MyChart patient portal, which many patients already use. Epic integration means clinicians are able to stay within their existing workflow environment as well.

Many provider organizations are in the early phases of their virtual care programs where showing an ROI is an important milestone and one that organizations want to achieve as soon as possible, KLAS notes. “A key promise from vendors is that their technology and accumulated expertise will result in a fast start and continuous acceleration. When this comes at significant cost or progress is slower than expected, provider organizations can experience disappointment,” the KLAS researchers wrote.

When it comes to getting their money’s worth and achieving desired outcomes, Epic and InTouch are rated highest among fully rated vendors, and swyMed and Vidyo perform well among their smaller groups of respondents, KLAS researchers note.

“For each vendor, the current value proposition is somewhat narrow but well understood: Epic’s use is limited to existing patients of Epic EMR customers; InTouch is used primarily for consults; swyMed is used by respondents primarily for mobile, first responder needs; Vidyo delivers video-conferencing tools,

which are typically combined with other VCP solutions. SnapMD is seen as a low-cost option, but some customers say the impact has been limited. Commentary from VSee customers suggests a similar experience,” KLAS researchers wrote in the report.

Many healthcare organizations are early on in their virtual care journeys, and their ability to achieve desired results depends on guidance from vendors. According to KLAS’ analysis, swyMed and InTouch receive the most praise for taking initiative in proactively guiding customers and also in quickly responding to support problems.

While respondents praise American Well’s platform scalability, some customers blame the vendor’s “exponential” growth for staffing shortages that have led to implementation holdups and backlogged service requests. Some SnapMD customers say hard-to-beat pricing comes with a support model that is spare in terms of providing tailored guidance, according to the KLAS report.

Most vendors offer two additional options that can help accelerate customers’ expansion and growth—supplemental services, including added-cost advisory and outsourced services, and tools that automate patient-facing tasks that traditionally require additional staff. I

KLAS found that few customers mentioned these options in top-of-mind conversations. “Respondents who spoke of their vendor’s supplemental services most often referred to marketing support or strategic planning services from vendors American Well, MDLIVE, or Zipnosis. Those who referred to task automation report patient-self-service capabilities around check-in, scheduling, surveys, and/or patient flow from InTouch Health (TruClinic), Epic, MDLIVE, or Zipnosis,” the KLAS researchers wrote.

Neonatal video-assisted resuscitation reduces transfers from hospitals without newborn intensive care units and provides significant cost savings, according to study published in the November issue of Health Affairs.

The study authors, led by Jordan Albritton of Intermountain Healthcare, examined a newborn telehealth program implemented at eight Intermountain Healthcare community hospitals in November 2014–December 2015 and the impact on the transfer of newborns from those eight hospitals to level 3 newborn intensive care units.

Studies show that 10 percent of newborns require assistance breathing at birth, and 1 percent require extensive resuscitation. At Intermountain Healthcare, approximately 1–2 percent of all babies born in suburban and rural hospitals are transferred to newborn intensive care units (NICUs) for higher-level care, according to the study.

In response to the need to improve outcomes for complex newborn patients, an innovative telehealth program was established at Intermountain Healthcare in 2013 to provide synchronous, video-assisted resuscitation (VAR), bringing a neonatologist to the bedside. As a result, access to specialized neonatal services in rural and suburban settings is no longer limited to telephone calls or the arrival of a neonatal transport team, the study authors wrote.

While telehealth can facilitate video connections between neonatologists at tertiary care centers and providers at smaller hospitals, there is little empirical evidence about the benefits of telehealth programs for neonatal resuscitation, according to the study authors.

Although Intermountain Healthcare began using telehealth technologies in 2013, the current VAR program was implemented in the period November 2014–December 2015. Today, neonatologists from four level 3 NICUs provide VAR support for nineteen referring hospitals.

As part of the study, the researchers evaluated eight hospitals that contained either well-baby (level 1) or special care (level 2) nurseries staffed by physicians, advanced practice clinicians, nurses, respiratory therapists, and other health care professionals. T

The study found that video-assisted resuscitation was associated with a reduction of 0.70 transfers per facility-month and a 29.4 percent reduction in a newborn’s odds of being transferred. Annually, this resulted in 67.2 fewer transfers and an estimated cost savings of $1.2 million per year.

“This program helps keep newborns in level 1 or 2 nurseries, which in turn allows families to stay closer to home, improves social support, and increases the revenue of community hospitals while reducing costs and risks associated with transfers,” the study authors wrote. “Payers should consider reimbursement for pediatric subspecialty telehealth consults for neonates in level 1 and 2 nurseries. Through improvements in care quality and cost savings, this service would likely pay for itself many times over.

However, the authors also note that lack of reimbursement for telehealth services limits widespread implementation.

“Policy changes are necessary to align payment incentives and promote the use of telehealth services,” the study authors wrote.